It is no secret that care for the elderly in Estonia has changed a lot in the last three decades. Joining the European Union brought the requirement to comply with the latest directives and also set new quality standards for our social welfare institutions.

However in Estonia the disadvantages of nursing homes are poor complex care, a lack of trained staff, insufficient funding, but also a negative psychological impact on the employees – such as burnout, mental and physical violence by residents, etc. – and a high number of occupational diseases and accidents. The influence of the legacy of the Soviet Union can still be felt.

A nursing home is not (yet) a place where people want to go to

“We have accepted a situation where a nursing home is not an institution where a person would like to go to, but rather an institution where someone decides to place another person,” Jaana Sepp, the new doctoral graduate, told the news portal Novaator. According to her, the organisation of work in social welfare institutions also leaves something to be desired.

How to improve the quality of nursing homes and nursing services in a situation like this?

In her doctoral thesis Safety Culture Framework for Nursing and Care Institutions, Sepp acknowledges that right now, both the health care and social welfare systems need to be changed and innovated.

This is where safety culture is a key factor in ensuring a safe and high-quality service. In organisations with a good safety culture, employees are committed to safety, there are fewer occupational accidents, and the organisation’s performance is in line with its goals.

In her doctoral dissertation, Sepp developed a theory based on the understanding that safety and the quality of services provided depend on the behavior of employees. “From the point of view of an organisation, it is important to create a culture that would lead to all members being committed to safety and all preventive measures being implemented, ensuring the physical and psychological well-being of employees and residents,” says Sepp in her dissertation.

Employees’ fear of punishment

The aim of the thesis is to create a holistic framework for the safety culture of health care and social welfare institutions, which is based on potential safety predictors and promotes the safety and well-being of care workers and patients.

To achieve this aim, the author conducted four surveys in 2016–2017, in which a total of 23 health (7) and social welfare institutions (16) participated. The results revealed that although care workers find the safety climate to be good, it is not reflected in their behaviour. Learning from mistakes and recording mistakes are not common practices in Estonian social welfare and health care institutions. Fear of punishment and stigmatisation are significant obstacles. The results of the survey showed that care workers perceive their workload to be high, which affects their mental health and potential work outcomes.

The main results of the doctoral thesis

The main contribution of the doctoral thesis to the theory of organisational culture is a new interpretation of the approach to differentiation. While it has previously been pointed out that different groups of health care organisations may have their own safety culture, the results of the doctoral thesis revealed that one group of specialists may also have a similar safety approach and culture on the state level. However, from a management perspective, it is important to recognise the needs and limitations of an organisation that result from the human component. According to the research, care workers do not perceive safety as a value in the organisation, but rather a doctrine of national legislation.

Jaana Sepp finds the second contribution of the doctoral thesis to be the additions to the approach of Reason and Hobbs (2003). In addition to the following subcultures of the safety culture: fairness, reporting, and learning, cultures of professional competence and psychosocial well-being need to be created in health care and social welfare institutions.  The proposed safety culture framework creates a precondition for the safe behaviour of workers and thus for the provision of a high-quality service, in particular through the central continuous assessment and improvement of subcultures.

The third important contribution is the choice of tried and tested instruments that can be used to assess safety culture in a multidisciplinary way.

The thesis also has practical value. For example, one of the author’s recommendations is to supplement the curriculum for care workers with an independent safety module, which would increase the workers’ understanding of safety, factors influencing safety behaviour, and consequences. The current model does not address the issue in a comprehensive way. An important input is the recommendation to update the training programme for health care and social welfare managers, according to which a manager should be able to assess the safety culture and interpret the results of the measurement instruments.